Feit Physiotherapy Ltd

Feit Physiotherapy Ltd.

Date: ______

Name: ______Family/Referring Doctor______

Address: ______Phone (Home)______

______(Mobile)______

City: ______Emergency Contact and Number:

Post Code: ______

Date of Birth: ______Health Card: ______

Area of Injury: ______Date of Injury: ______

Is your injury covered by WCB? YES/NO Claim Number: ______

Case Worker: ______

Occupation: ______Employer: ______

Is your injury covered by Motor Vehicle Insurance? YES/NO

Insurance Company: ______

Insurance Contact Person: ______

Policy/Claim Number: ______

Is your injury covered by private medical insurance? YES/NO

Insurance Company: ______Policy Number______

Name of Policy Holder: ______ID Number: ______

Assignment:

I hereby authorize my insurance benefits to be paid directly to Feit Physiotherapy Ltd. and am financially responsible for non-covered services.

WCB claims: In the event that WCB declines approval of your Physiotherapy claim, I acknowledge that I am financially responsible for non-covered services.

MVA claims: In the event that your motor vehicle insurance provider declines approval of your Physiotherapy claim, I acknowledge that I am financially responsible for non-covered services.

Patient Signature: ______Date: ______